Review

. 2025 Oct;15(10):1032-1069.

doi: 10.1002/alr.23596. Epub 2025 May 15.

Expert Strategies: Skull Base Reconstruction-Global Perspectives, Insights, and Algorithms through a Mixed Methods Approach

Edward C Kuan¹, Vidit Talati², Jagatkumar A Patel^{3

4}, Theodore V Nguyen⁵, Arash Abiri⁵, Jonathan C Pang⁵, Khodayar Goshtasbi⁵, Lauren Liu⁵, John R Craig⁶, Peter Papagiannopoulos², Katie M Phillips⁷, Bobby A Tajudeen², Nithin D Adappa⁸, James N Palmer⁸, Ahmad R Sedaghat⁷, Eric W Wang⁹, Vijay Anand¹⁰, Pete S Batra², Marvin Bergsneider¹¹, Manuel Bernal-Sprekelsen¹², Benjamin S Bleier¹³, Paolo Cappabianca¹⁴, Ricardo L Carrau¹⁵, Roy R Casiano¹⁶, Paolo Castelnuovo¹⁷, Luigi M Cavallo¹⁴, Marc A Cohen¹⁸, Iacopo Dallan¹⁹, Jean Anderson Eloy²⁰, Ivan H El-Sayed²¹, James J Evans²², Juan C Fernandez-Miranda²³, Marco Ferrari²⁴, Sebastien Froelich²⁵, Paul A Gardner²⁶, Christos Georgalas²⁷, Stacey T Gray¹³, Ehab Y Hanna²⁸, Richard J Harvey²⁹, Sang Duk Hong³⁰, Peter H Hwang³¹, Daniel F Kelly³², Doo-Sik Kong³³, Ming-Ying Lan³⁴, John Y K Lee³⁵, Corinna G Levine¹⁶, James K Liu³⁶, Davide Locatelli³⁷, Cem Meço^{18

38

39}, Erin L McKean⁴⁰, Piero Nicolai²⁴, Gurston G Nyquist⁴¹, Kazuhiro Omura⁴², Thibault Passeri²⁵, Zara M Patel³¹, Maria Peris Celda⁴³, Carlos Pinheiro Neto⁴⁴, Danny M Prevedello⁴⁵, Mindy R Rabinowitz⁴¹, Shaan M Raza⁴⁶, Pablo F Recinos⁴⁷, Marc R Rosen⁴¹, Zoukaa B Sargi¹⁶, Rodney J Schlosser⁴⁸, Theodore H Schwartz⁴⁹, Raj Sindwani⁵⁰, Carl H Snyderman⁹, Aldo C Stamm⁵¹, Brian D Thorp⁵², Mario Turri-Zanoni¹⁷, Marilene B Wang⁵³, Wei-Hsin Wang⁵⁴, Ian J Witterick⁵⁵, Tae-Bin Won⁵⁶, Bradford A Woodworth⁵⁷, Peter-John Wormald⁵⁸, Gabriel Zada⁵⁹, Shirley Y Su²⁸

Affiliations

¹ Departments of Otolaryngology, Head and Neck Surgery and Neurological Surgery, University of California, Irvine, Orange, California, USA.
² Department of Otorhinolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.
³ Kaiser Permanente, Orange County, Anaheim, California, USA.
⁴ Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
⁵ Department of Otolaryngology, Head and Neck Surgery, University of California, Irvine, Orange, California, USA.
⁶ Department of Otolaryngology, Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA.
⁷ Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
⁸ Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
⁹ Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹⁰ Department of Otolaryngology, Head and Neck Surgery, New York-Presbyterian/Cornell University, Weill Cornell Medical College, New York, New York, USA.
¹¹ Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.
¹² Otorhinolaryngology Department, Surgery and Medical-Surgical Specialties Department, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
¹³ Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.
¹⁴ Department of Neurosurgery, Federico II University Hospital, Naples, Italy.
¹⁵ Department of Otolaryngology, Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA.
¹⁶ Department of Otolaryngology, Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹⁷ Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, ASST Sette Laghi Hospital, Varese, Italy.
¹⁸ Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
¹⁹ Department of Otolaryngology, Head and Neck Surgery, Pisa University Hospital, Pisa, Italy.
²⁰ Department of Otolaryngology, Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
²¹ Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.
²² Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
²³ Department of Neurological Surgery, Stanford University School of Medicine, Palo Alto, California, USA.
²⁴ Department of Neurosciences, Section of Otorhinolaryngology, Head and Neck Surgery, University of Padova, Padova, Italy.
²⁵ Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France.
²⁶ Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
²⁷ Department of Otorhinolaryngology, Head and Neck Surgery, University of Nicosia Medical School, Nicosia, Cyprus.
²⁸ Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
²⁹ Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of South Wales, Sydney, NSW, Australia.
³⁰ Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
³¹ Department of Otolaryngology, Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.
³² Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California, USA.
³³ Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
³⁴ Department of Otorhinolaryngology, Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
³⁵ Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
³⁶ Department of Neurological Surgery, New Jersey Medical School, Newark, New Jersey, USA.
³⁷ Department of Biotechnology and Life Sciences, Division of Neurological Surgery, University of Insubria, ASST Sette Laghi Hospital, Varese, Italy.
³⁸ Department of Otorhinolaryngology, Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey.
³⁹ Department of Otorhinolaryngology, Head and Neck Surgery, Salzburg Paracelsus Medical University, Salzburg, Austria.
⁴⁰ Department of Otolaryngology, Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA.
⁴¹ Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁴² Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan.
⁴³ Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.
⁴⁴ Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.
⁴⁵ Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA.
⁴⁶ Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.
⁴⁷ Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
⁴⁸ Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁴⁹ Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
⁵⁰ Head and Neck Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
⁵¹ São Paulo ENT Center (COF), Edmundo Vasconcelos Complex, São Paulo, Brazil.
⁵² Department of Otolaryngology, Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
⁵³ Department of Otolaryngology, Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA.
⁵⁴ Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
⁵⁵ Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.
⁵⁶ Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
⁵⁷ Department of Otolaryngology, Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁵⁸ Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, SA, Australia.
⁵⁹ Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

PMID: 40371737
PMCID: PMC12503090
DOI: 10.1002/alr.23596

Review

Expert Strategies: Skull Base Reconstruction-Global Perspectives, Insights, and Algorithms through a Mixed Methods Approach

Edward C Kuan et al. Int Forum Allergy Rhinol. 2025 Oct.

. 2025 Oct;15(10):1032-1069.

doi: 10.1002/alr.23596. Epub 2025 May 15.

Authors

Affiliations

¹ Departments of Otolaryngology, Head and Neck Surgery and Neurological Surgery, University of California, Irvine, Orange, California, USA.
² Department of Otorhinolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.
³ Kaiser Permanente, Orange County, Anaheim, California, USA.
⁴ Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
⁵ Department of Otolaryngology, Head and Neck Surgery, University of California, Irvine, Orange, California, USA.
⁶ Department of Otolaryngology, Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA.
⁷ Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
⁸ Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
⁹ Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
¹⁰ Department of Otolaryngology, Head and Neck Surgery, New York-Presbyterian/Cornell University, Weill Cornell Medical College, New York, New York, USA.
¹¹ Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.
¹² Otorhinolaryngology Department, Surgery and Medical-Surgical Specialties Department, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
¹³ Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.
¹⁴ Department of Neurosurgery, Federico II University Hospital, Naples, Italy.
¹⁵ Department of Otolaryngology, Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA.
¹⁶ Department of Otolaryngology, Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹⁷ Department of Biotechnology and Life Sciences, Division of Otorhinolaryngology, University of Insubria, ASST Sette Laghi Hospital, Varese, Italy.
¹⁸ Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
¹⁹ Department of Otolaryngology, Head and Neck Surgery, Pisa University Hospital, Pisa, Italy.
²⁰ Department of Otolaryngology, Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
²¹ Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.
²² Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
²³ Department of Neurological Surgery, Stanford University School of Medicine, Palo Alto, California, USA.
²⁴ Department of Neurosciences, Section of Otorhinolaryngology, Head and Neck Surgery, University of Padova, Padova, Italy.
²⁵ Department of Neurosurgery, Lariboisière Hospital, University of Paris Diderot, Paris, France.
²⁶ Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
²⁷ Department of Otorhinolaryngology, Head and Neck Surgery, University of Nicosia Medical School, Nicosia, Cyprus.
²⁸ Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
²⁹ Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of South Wales, Sydney, NSW, Australia.
³⁰ Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
³¹ Department of Otolaryngology, Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.
³² Department of Neurosurgery, Pacific Neuroscience Institute, Santa Monica, California, USA.
³³ Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
³⁴ Department of Otorhinolaryngology, Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
³⁵ Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
³⁶ Department of Neurological Surgery, New Jersey Medical School, Newark, New Jersey, USA.
³⁷ Department of Biotechnology and Life Sciences, Division of Neurological Surgery, University of Insubria, ASST Sette Laghi Hospital, Varese, Italy.
³⁸ Department of Otorhinolaryngology, Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey.
³⁹ Department of Otorhinolaryngology, Head and Neck Surgery, Salzburg Paracelsus Medical University, Salzburg, Austria.
⁴⁰ Department of Otolaryngology, Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA.
⁴¹ Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁴² Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan.
⁴³ Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.
⁴⁴ Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.
⁴⁵ Department of Neurological Surgery, The Ohio State University, Columbus, Ohio, USA.
⁴⁶ Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.
⁴⁷ Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
⁴⁸ Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁴⁹ Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
⁵⁰ Head and Neck Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
⁵¹ São Paulo ENT Center (COF), Edmundo Vasconcelos Complex, São Paulo, Brazil.
⁵² Department of Otolaryngology, Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
⁵³ Department of Otolaryngology, Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA.
⁵⁴ Division of General Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
⁵⁵ Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.
⁵⁶ Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
⁵⁷ Department of Otolaryngology, Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁵⁸ Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, SA, Australia.
⁵⁹ Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

PMID: 40371737
PMCID: PMC12503090
DOI: 10.1002/alr.23596

Abstract

Objective: There is limited consensus on endoscopic skull base surgery (ESBS) reconstruction principles. This study aims to generate comprehensive themes regarding ESBS reconstruction by pooling the experiences of ESBS experts, with comparison to a literature review of current published evidence.

Methods: Structured qualitative interviews of ESBS experts regarding postoperative management and reconstruction of various defect locations were conducted.

Results: A total of 68 experts comprising 40 academic teams across 13 countries with an average of 18 years of ESBS experience were included. We propose 10 stepwise algorithms for common skull base reconstruction scenarios based on these expert interviews. When available, the nasoseptal flap is used for all high_flow cerebrospinal leak defects. Multilayered reconstruction is favored at all anatomical subsites with increasing number of layers for increasing defect size and complexity. Heterogeneity exists in terms of inlay technique and materials, free grafting versus various pedicled flap options for low-flow defects or in the absence of a nasal septum, nasal packing, tissue sealant, lumbar drain use, and postoperative management. Commonalities and discrepancies between experts were summarized.

Conclusion: Skull base reconstruction and post-ESBS management is highly complex with a wide variety of practice patterns and expert strategies. Further research of higher quality evidence is warranted to identify optimal management patterns, though the current work aims to inform surgeons on these controversial areas by drawing from numerous experiences.

Keywords: CSF leak repair; anterior cranial fossa; cerebrospinal fluid leak; encephalocele; expert algorithms; posterior cranial fossa; postoperative precautions; sella; skull base reconstruction; suprasellar.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflicts of interest.

Figures

**FIGURE 1**
Expert reconstruction algorithm for a sellar defect with a “weeping” leak. ECM, extracellular matrix; FMG, free mucosal graft; INF, intranasal flap (excluding nasoseptal flap); NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 2**
Expert reconstruction algorithm for a sellar defect with a visible hole in the diaphragm. ECM, extracellular matrix; FMG, free mucosal graft; INF, intranasal flap (excluding nasoseptal flap); NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 3**
Expert reconstruction algorithm for suprasellar (transtuberculum/transplanum) defects. ECM, extracellular matrix; ENF, extranasal flap; FL, fascia lata; FMG, free mucosal graft; INF, intranasal flap (excluding nasoseptal flap); NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 4**
Expert reconstruction algorithm for anterior cranial fossa (transcribriform/transethmoid) defects. ACF, anterior cranial fossa; ECM, extracellular matrix; FL, fascia lata; INF, intranasal flap (excluding nasoseptal flap); NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 5**
Expert reconstruction algorithm for posterior cranial fossa (transclival and/or craniocervical junction) defects. ECM, extracellular matrix; ENF, extranasal flap; FL, fascia lata; INF, intranasal flap (excluding nasoseptal flap); NSF, nasoseptal flap; PCF, posterior cranial fossa. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 6**
Expert reconstruction algorithm for traumatic ethmoid defects. ECM, extracellular matrix; FMG, free mucosal graft; NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 7**
Expert reconstruction algorithm for iatrogenic ethmoid defects. ECM, extracellular matrix; FMG, free mucosal graft; NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 8**
Expert reconstruction algorithm for frontal sinus posterior table defects. ECM, extracellular matrix; FMG, free mucosal graft; NSF, nasoseptal flap; PT FS, posterior table of frontal sinus. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 9**
Expert reconstruction algorithm for spontaneous ethmoid leaks and encephaloceles. ECM, extracellular matrix; FMG, free mucosal graft; NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 10**
Expert reconstruction algorithm for spontaneous sphenoid sinus lateral recess leaks and encephaloceles. ECM, extracellular matrix; FMG, free mucosal graft; NSF, nasoseptal flap. Italicized rows indicate most common response among experts for specific inlay/onlay.

**FIGURE 11**
Expert algorithm for workup of suspected early postoperative CSF leak, with frequencies of expert responses.

**FIGURE 12**
Graphical depictions of inlay and onlay skull base reconstruction based on defect site, in accordance with the algorithms highlighted in Figures 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. All are sagittal views unless noted otherwise. Original illustrations are adapted from the style of Snyderman et al. [34]. (A) Sellar defect with a “weeping” leak and sellar defect with a visible diaphragm defect with no septum. (B) Sellar defect with visible diaphragm defect with septum. (C) Suprasellar defect. (D) Traumatic or iatrogenic ethmoid defect and spontaneous ethmoid meningoencephalocele/CSF leak. (E) Posterior table of frontal sinus defect. (F) Spontaneous sphenoid (lateral recess) meningoencephalocele/CSF leak (coronal view). (G) Anterior cranial fossa defect with septum. (H) Anterior cranial fossa defect without septum. (I) Posterior cranial fossa defect. *Abbreviations*: ACF, anterior cranial fossa; ECM, extracellular matrix; ENF, extranasal flap; FL, fascia lata; FMG, free mucosal graft; INF, intranasal flap (excluding nasoseptal flap); NSF, nasoseptal flap; PCF, posterior cranial fossa; PT FS, posterior table of frontal sinus; SS, suprasellar.

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Expert Strategies: Skull Base Reconstruction-Global Perspectives, Insights, and Algorithms through a Mixed Methods Approach

Affiliations

Expert Strategies: Skull Base Reconstruction-Global Perspectives, Insights, and Algorithms through a Mixed Methods Approach

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical